Can social care ever become a true political priority?

In her speech at the Nuffield Trust Summit in March, Baroness Casey delivered a damning verdict on the state of social care and called for a moment of reckoning – a moment akin to 1948 for the NHS. She called out the underpayment of care workers, the dysfunctional provider market, a lack of ownership of the system and the struggles people face in accessing timely care. For anyone familiar with the sector, her diagnosis of the problems will not have been a surprise. What matters now is what happens next. 

Alongside some specific immediate asks of the government, Baroness Casey talked about the need for a “national conversation” to gain support from the public for reform. She talked of the need for honest debate and a public mandate from the people who pay for health and care through their taxes. Fourteen months into the Commission and with the pressures on social care only set to grow, a “conversation” may feel out of step with the urgency for change that is felt by anyone associated with social care. 

Social care reform is no stranger to the long grass. We’re not far off the 30-year mark since then Prime Minister Tony Blair kicked off the Sutherland Commission into the future of long-term care. The intervening period has been characterised by a series of failed attempts to bring about change. At the root of failure has been a political toxicity that has made politicians wary of leading the charge for reform. Is a public conversation a necessary step or is it just adding even further delay to reform? 

Why is social care so politically toxic?

Many have written about this before me, but still it seems to be poorly understood. The simple answer is that too few people understand what social care is, how it works or how essential it is until they or a family member need it. People generally don’t know that it can be difficult to access publicly funded care and that the costs of privately funding it can be significant. Around one-third of us think social care is part of the NHS and free at the point of use. It’s not clear whether the two-thirds of us who don’t think it’s part of the NHS have any better understanding of what it actually is. 

This lack of public understanding lies at the heart of the political problem. National debate tends to be dominated by concern about the NHS – the public is familiar with its constituent parts and able to engage in debate about the hospitals and GP surgeries and so on that might be under threat. The social care ‘crisis’, in contrast, unfolds quietly behind people’s front doors without the physical manifestation of ambulances queuing around the block. It constitutes the biggest part of local authority spend but is less visible than the other elements of council business – the bins, libraries and swimming pools that tend to feature prominently in debates around local elections. 

This invisibility means that it rarely becomes a political priority. That is, until is becomes very visible in high-profile debate that is underpinned by fundamental misunderstanding and low awareness. 

For instance, if you’re a voter who is under the impression that you’ve paid your taxes and national insurance all your life and, in return, will be looked after from cradle to grave, you are going to be understandably confused, and possibly angry, to hear that a politician is proposing a new tax or levy to pay for a service that you believe is currently free at the point of use. Or that funding is to be shifted from one service that is visible and valued (maybe hospitals, say, or public libraries) to fund social care – a service that you may have little understanding of and think holds little relevance to you or your family.

Parties across the political spectrum have exploited this lack of awareness in the run-up to previous elections and chosen to score political points over supporting long-term change. The most prominent examples were when Labour’s proposal for a National Care Service was labelled a death tax by the Conservatives during the 2010 election campaign; and when the Conservatives’ proposals for funding reform were called a dementia tax in the 2017 campaign. In both cases, the subsequent heavy losses sustained by the parties were blamed at least in part on the toxic social care debate that followed their proposals. 

Sadly, these experiences have exacerbated public misunderstanding of social care, reducing the debate to a narrow focus on inheritance and property, and have made politicians wary of raising the prospect of change.

Tick tock: getting the public on board

Arguably, the current Labour government had a window of opportunity when it took office to push through a programme of social care reform. It held a large parliamentary majority and could have used its political clout to implement its plans for a National Care Service that had been developed in the late 2000s and which had been further refined during the party’s time in opposition. But that opportunity was not grasped and, two years on, the clock is ticking and political capital is rapidly depreciating. 

All hopes for reform now lie in what comes from Baroness Casey’s Commission. But any plans that emerge from it will be in their infancy come the next election and their longevity will depend on the commitment of the next administration, on whichever side of the political divide they reside. For plans to reform social care to survive into the next parliament, they need to be politically salient – a vote winner not a gamble. Social care needs to be a visible priority for the public so that reform efforts cannot be rendered invisible by the next administration. 

We’ve had ‘public conversations’ on care before. Perhaps the most concerted was Labour’s Big Care Debate that ran for five months in 2009 and heard from 28,000 people directly, in addition to taking soundings via social media. It’s difficult to measure the extent to which the initiative cut through to the wider public but, disappointingly and despite explicit cross-party buy-in, political point-scoring proved just too tempting come election time.

More recently, a public deliberation exercise run by then Engage Britain sought to identify priorities for change, and some councils (Camden, for instance) are currently running their own public engagement initiatives to raise awareness and carve out a palatable route for reform. Any exercise spearheaded by Baroness Casey will need to be meaningful, swift and able to reach a broad audience so that social care holds relevance for a sizable proportion of the public, not just those in direct contact with services now.

Political bravery

Public support for change is a necessity. Without it, social care will always lack the political salience that governments need to make investment. But public support is unlikely to be enough on its own. Baroness Casey, after all, is unlikely to be in a position to force implementation of her plans and so must rely on the next government to see them through. A substantial amount of political bravery will be needed to make change a reality. 

Whatever the future holds, one thing is certain – as a society, we will need more social care and support, and that will come with a price tag. The current system concentrates resource on the very poorest with the very highest needs. If we want a system that supports more of us in future or that provides more or better care with better paid staff, uncomfortable decisions will need to be made. Those decisions may involve raising additional revenue from an increasingly stretched public or shifting funding away from one part of the public sector to better resource care services. 

With increasingly choppy political waters ahead of us, we will need political leaders who recognise the importance of care and support and who are prepared to stick their necks out to make social care a priority.